Adjustment of permissible exposure values to unusual work schedules

Research activities sought development of a method to adjust exposure limits for 694 substances for unusual work schedules. A consensus was established on the basic toxicological principle for adjustment; criteria for adjustment were selected by a panel of scientists coordinated by a committee of international experts and supported by toxicokinetic modeling; and a group of toxicologists attributed primary health effects and related adjustment category to each substance. A consensus among scientists and employers' and workers' representatives was established on the protocol of the application, in the field, of the adjusted exposure limits. The guiding toxicological principle for adjusting exposure standards to unusual work schedules is to guarantee an equivalent degree of protection for workers with unusual schedules as for workers with a conventional schedule of 8 hours per day, 5 days per week. The process of the adjustment is inspired from the Occupational Safety and Health Administration logic for attribution of primary health effects and adjustment categories ranging from no adjustment to daily or weekly adjustments. The adjusted exposure limits are calculated according to Haber's rule. Decisions on attribution of adjustment categories for the following toxicological effects were reached: respiratory sensitizers (asthma); skin sensitizers; tissue irritants versus tissue toxicants; methemoglobinenia-causing agents; cholinesterase inhibitors; and reproductive system toxicants and teratogens. A simple procedure is presented to facilitate the calculation, application, and interpretation of the adjusted exposure limits.

Training of occupational physicians in The Netherlands with regard to occupational health services delivered to the population

In the Netherlands, the need for a basically new approach to education and training in occupational medicine was felt by professionals, students, schools and occupational health services (OHS) in the early 1990s. After an inventory of the problems and shortcomings of the traditional curriculum, the Netherlands School of Occupational Health defined the framework for a new curriculum. In this article the background, principles and structure of the new curriculum are described. Three principles shape the curriculum: the needs of OHS; professional standards; and the state-of-the-art. The characteristics of the new curriculum are: interaction between theory and practice; students' self-management of the learning process; co-makership with OHS; and multidisciplinarity. The curriculum consists of a course/theory and a practical part. Most of the theoretical part is presented to so called core group of 12 students, which is to be maintained during the full course period of 4 years. The adage for the practical part to be spent in a certified OHS institution is: "the best teaching OHS are learning OHS". In 1999, the first group of students entered the renewed curriculum. First impressions of the experience gained are presented.

Ethics in the practice of occupational medicine

Ethical considerations are often important when managers make organizational decisions. There are two ethical approaches commonly employed when making decisions. The first is deontology or the existence of an absolute standard that does not change over time. Decisions made by reference to a creed or professional code are uniformly consistent. The second ethical system is teleology or optimization. Decisions are made to optimize the outcome, and they can be inconsistent over time. Health professionals must often choose their allegiance from several alternatives. These conflicts must be recognized and reconciled. Students can benefit from the inclusion of ethical training during their professional preparation.

Routine diagnostic procedures for chronic encephalopathy induced by solvents: survey of experts

OBJECTIVES

To study the routine diagnostic procedures used in different countries for chronic toxic encephalopathy (CTE) induced by solvents.

METHODS

By means of a postal questionnaire selected international experts were asked about the methods they use to diagnose patients suspected of having CTE induced by solvents, the number of patients, entrance criteria, and the results of these diagnostic procedures.

RESULTS

18 Experts working in 18 diagnostic centres responded. Most of them agreed that a diagnostic procedure for CTE induced by solvents should contain an interview and neurological, physical, and neuropsychological examinations. However, the tests used were very different, as were the classifications for CTE. Depending on the institute, a diagnosis of CTE was made in 6%--70% of the referred patients. The proportion of patients with CTE stage I ranged from 0% to 33%, stage II from 5% to 100%, and stage III from 0% to 95%.

CONCLUSION

The intentions of the two 1985 conferences that aimed at clarity and uniformity of diagnosis of CTE induced by solvents are far from reached. It is possible, now the conditions are more favourable, to aim at this important goal and recommend some refinement of the then proposed criteria.

Chest radiography in the diagnosis of pneumoconiosis

SETTING

Report of a workshop on Occupational Lung Diseases, IUATLD Respiratory Disease Section, Bangkok 1998.

OBJECTIVE

To describe the role of chest radiography in the diagnosis of pneumoconiosis in clinical practice.

MATERIALS AND METHODS

Pneumoconiosis, defined as the accumulation of dust in the lung and tissue reaction to its presence, is diagnosed and monitored by X-ray techniques. The International Labour Organization (ILO) developed a descriptive system of the radiographic appearances of pneumoconiosis using standard chest radiographs to classify the type and category of profusion of small opacities seen in the lung fields, as well as the width and extent of pleural changes and other abnormalities of a more general nature.

RESULTS

The pertinence of the ILO classification has been demonstrated by studying the correlation between anatomic lesions and chest X-ray features. Other imaging techniques have been proposed over the past few years, including computed tomography and magnetic resonance imaging. However, until now they have remained essentially complementary to verify an unclear aspect of particular features of a given radiograph, rather than as the standard method of diagnosis.

CONCLUSION

Chest radiography remains the principal tool in the diagnosis of pneumoconiosis, and has the advantages of the large number of units in service throughout the world, their relatively low cost, and the widely-accepted ILO classification.

Improving the quality of workers' compensation health care delivery: the Washington State Occupational Health Services Project

This article has summarized research and policy activities undertaken in Washington State over the past several years to identify the key problems that result in poor quality and excessive disability among injured workers, and the types of system and delivery changes that could best address these problems in order to improve the quality of occupational health care provided through the workers' compensation system. Our investigations have consistently pointed to the lack of coordination and integration of occupational health services as having major adverse effects on quality and health outcomes for workers' compensation. The Managed Care Pilot Project, a delivery system intervention, focused on making changes in how care is organized and delivered to injured workers. That project demonstrated robust improvements in disability reduction; however, worker satisfaction suffered. Our current quality improvement initiative, developed through the Occupational Health Services Project, synthesizes what was learned from the MCP and other pilot studies to make delivery system improvements. This initiative seeks to develop provider incentives and clinical management processes that will improve outcomes and reduce the burden of disability on injured workers. Fundamental to this approach are simultaneously preserving workers' right to choose their own physician and maintaining flexibility in the provision of individualized care based on clinical need and progress. The OHS project then will be a "real world" test to determine if aligning provider incentives and giving physicians the tools they need to optimize occupational health delivery can demonstrate sustainable reduction in disability and improvements in patient and employer satisfaction. Critical to the success of this initiative will be our ability to: (1) enhance the occupational health care management skills and expertise of physicians who treat injured workers by establishing community-based Centers of Occupational Health and Education; (2) design feasible methods of monitoring patient outcomes and satisfaction with the centers and with the providers working with them in order to assess their effectiveness and value; (3) establish incentives for improved outcomes and worker and employer satisfaction through formal agreements with the centers and providers; and (4) develop quality indicators for the three targeted conditions (low back sprain, carpal tunnel syndrome, and fractures) that serve as the basis for both quality improvement processes and performance-based contracting. What lessons or insights does our experience offer thus far? The primary lesson is the importance of making effective partnerships and collaborations. Our policy and research activities have benefited significantly from the positive relationship the DLI established with the practice community through the Washington State Medical and Chiropractic Associations and from the DLI's close association with the Healthcare Subcommittee of the Workers' Compensation Advisory Committee. This committee is established by state regulation and serves as a forum for dialogue between the committee and the employer and labor communities. Our experience thus underscores the importance of establishing broad-based support for delivery system innovations. Our research activities have also benefited from the close collaboration between DLI program staff and UW health services researchers. The DLI staff brought important program and policy experience, along with an appreciation of the context and environment within which the research, policy, and R&D activities were conducted. The UW research team brought scientific rigor and methodological expertise to the design and implementation of the research and policy activities. In Washington State, the DLI represents a "single payer" for the purposes of workers' compensation. As discussed earlier, Washington State, along with five other states, has a state-fund system that requires all employers that are not self-insured to purchase workers' compensation insurance through the state fund. No matter what one feels about the merits or drawbacks of a single-payer system of health care financing, the fact is that such a system creates important opportunities for policy initiatives and for research and evaluation. Our ability to access population-based data on injured workers and to develop policy initiatives through innovation and pilot testing to assess whether proposed changes are really improvements has been critical. Understanding what works within the constraints and complexities of the system on a small scale is critical in order to bring forth policy and processes that will be of value systemwide. Finally, we note that general medical care faces many of the same quality-related problems and challenges as occupational health care. Medical care for chronic diseases, such as diabetes, is often fragmented and uncoordinated. (ABSTRACT TRUNCATED)

[Quality system and training of the occupational physician: a referral macromodel]

The progressive changes in society, in the working environment and in organization are leading to changes in the role of the occupational physician. This process requires a continuing renewal of the training curricula of the University Schools of Occupational Medicine. The revised curricula provide more appropriate guidance by setting learning objectives (knowledge an occupational physician should have in each formative area) and training objectives (experience an occupational physician should have). These changes require a new approach in delivering a successful teaching-learning service. A Quality System (QS) for training is a management tool aimed at identifying the training products required by the complex customer system (society, institutions, students, firms). A QS anticipates customers' needs and satisfies them; it guarantees the quality of the results by monitoring resources, activities and processes that directly influence the quality of the service/training product. The system is mainly based on the development and exploitation of the internal expertise and on the innovative approach by the customer-oriented structures. The system is also based on innovation of methods (methods of planning, delivering and evaluating) and on rationalization of the processes and the connected procedures of training tools, professional abilities, training and managerial documentation. Therefore, although all Specialization Schools share the same mission, i.e. training of the Specialist in occupational medicine, each School should adopt a Quality Policy in accordance with strategic choices made by the School in relation to its specific, history, values, perceived vision and situation of the market.

[Clinico-occupational history in neurology and scope of occupational neurology]

INTRODUCTION

The occupational environment generates a large amount of illness which involves several specialities, including neurology. However, there is little awareness--or little training--in this field as in most medical specialities, since in the basic tool of a doctor's work, the clinical history, importance is sometimes given to aspects such as sex, race etc. and data referring to the patient's occupation and the risks this may imply for his health are considered to matter less.

DEVELOPMENT

The creation of a new working party within the Sociedad Española de Neurología, that of Neurología del Trabajo (Occupational Neurology) aims to correct these deficiencies, and to make colleagues aware of the importance of assessing the occupational hazards of patients and attempt to relate them to the clinical picture which presents. In order to do this we must first mark out our field of action, the commonest diseases and the administrative route used for claiming for these conditions. Then we will have to evaluate our relationship with other professional colleagues in the field of occupational health and finally consider the tasks of training, investigation and promotion of occupational health.

Adjustment of occupational exposure limits for unusual work schedules

A review of literature relating to the issue of adjustments of occupational exposure limits for unusual work shifts and unusual work schedules is described. The important issues relating to various adjustment models are discussed, and a number of conclusions are drawn. Tables of adjustment factors for 34 specific contaminants for 2 unusual schedules are given. A simple approach for use by industrial hygienists is proposed.

The application of the methods of evidence-based practice to occupational health

Evidence-based methods of practice are becoming widely used in many areas of healthcare. The techniques of data appraisal, systematic review and meta-analysis and their application to clinical and preventative medicine through clinical guidelines and economic analyses are well established. These methods have only been applied to occupational health risks and interventions in a very limited way and there is considerable scope for wider use, especially in the clinical aspects of practice. This should improve the quality of prevention and would also enable practitioners to give more soundly based advice and to secure their professional positions as providers of quality assured information. Human and financial resources and commitment to the development of evidence-based approaches by the professions and those they work for are pre-requisites for success.

Occupational and environmental medicine: sustainable development?

Occupational medicine is evolving to meet the needs of the 21st century. There is a need to define the remit of occupational and environmental medicine in order to facilitate the development and maintenance of requisite competencies, the establishment of educational goals for practitioners and production of a professional product for the global market place. The delivery of occupational health services will be underpinned by quality assurance systems.

[Ethical problems in health surveillance]

Surveillance of workers' health in the field of occupational medicine poses substantial ethical problems in view of occupational medicine's complex responsibilities towards workers and employers, preventive and protection services, workers' representatives, public healthcare and preventive medicine facilities, controlling agencies and judicial authorities. Potentially conflicting rights and duties often come into play in this sector. In the last few years various international and national bodies have drawn up codes of ethics or guidelines for the conduct of physicians in occupational medicine, three of which are of particular importance: 1) The International Ethical Code of the International Commission on Occupational Health (ICOH, 1992); 2) The Code of Conduct of the National Association of Company Doctors (ANMA, 1997); 3) The Technical and Ethical Guidelines for workers' health (ILO, 1998). The chief purpose of all these documents is to safeguard the health of workers and to guarantee the safety of the workplace by defining programmes of health supervision to match specific risks. The methods should be non-invasive and should allow for a check or efficiency. The physician is expected to have a high degree of professionalism and up-to-date skills; to be independent and impartial; to be reserved and capable of inter-disciplinary co-operation. On the basis of the above documents, a number of problematic aspects may be appraised concerning the relationship between the occupational health physician responsible for the surveillance activities of the local health authority and the relative company physician. The documents stress the importance of keeping up to date and of quality, fields in which the dominant role played by Scientific Societies is underlined. Finally it is recommended that health supervision be arranged in such a manner as to foster the professionalism and responsibility of the physician in charge rather than the formal implementation of health-care procedures that are inadequate and not in line with up-to-date scientific knowledge.

[Health surveillance in the parliamentary proposal for the development of a single text of general regulations for the protection of health and work safety]

The goal of the Work Commission of the Senate, making a proposal of a consolidation of several regulations in force, inspired to different philosophies, sometimes going to long time ago. The commission intends to issue an "up to date" law. With regard to the sanitary surveillance, physicians independence and capacity are of paramount importance. The physician capability on a continuous updating. The occupational health physician is concerned with the relationship between people and environment, therefore is duty can not come to the mere clinical examination: he must be involved in risk assessment, a basic factor in prevention, that must be absolutely reliable.

ACOEM position statement. Spirometry in the occupational setting. American College of Occupational and Environmental Medicine

This position statement reviews several aspects of spirometric testing in the workplace, where spirometry is employed in the primary, secondary, and tertiary prevention of occupational lung disease. Primary prevention includes pre-placement and fitness-for-duty examinations as well as research and monitoring of health status in groups of exposed workers; secondary prevention includes periodic medical screening of individual workers for early effects of exposure to known occupational hazards; and tertiary prevention includes clinical evaluation and impairment/disability assessment. For all of these purposes, valid spirometry measurements are critical, requiring: documented spirometer accuracy and precision, a rigorous and standardized testing technique, standardized measurement of pulmonary function values from the spirogram, adequate initial and refresher training of spirometry technicians, and, ideally, quality assessment of samples of spirograms. Interpretation of spirometric results usually includes comparison with predicted values and should also evaluate changes in lung function over time. Response to inhaled bronchodilators and changes in relation to workplace exposure may also be assessed. Each of these interpretations should begin with an assessment of test quality and, based on the most recent ATS recommendations, should rely on a few reproducible indices of pulmonary function (FEV1, FVC, and FEV1/FVC.) The use of FEF rates (e.g., the FEF25-75%) in interpreting results for individuals is strongly discouraged except when confirming borderline airways obstruction. Finally, the use of serial PEF measurements is emerging as a method for confirming associations between reduced or variable pulmonary function and workplace exposures in the diagnosis of occupational asthma. Throughout this position statement, ACOEM makes detailed recommendations to ensure that each of these areas of test performance and interpretation follow current recommendations/standards in the pulmonary and regulatory fields. Submitted by the Occupational and Environmental Lung Disorder Committee on November 16,1999. Approved by the ACOEM Board of Directors on January 4,2000.

Occupational diseases in the Czech Republic in the year 1998. The need for unifying European standards/criteria for all occupational diseases

In the Czech Republic, the Clinics and Departments for Occupational Medicine according to the legislation have the right to recognise occupational diseases. The diagnosis must correspond to the Czech list of occupational diseases, which is similar to the European list of occupational diseases. The exposure, sufficient enough to cause certain occupational disease, must be confirmed by regional industrial hygienists, responsible for hygienic control of the workplace. It is evident that the number of diseases is very much dependent upon the standards/criteria used to recognise occupational diseases. In the Czech Republic, the patients suffering from occupational diseases are given considerable financial compensations, which creates a great motivation for them to apply for occupational diseases. The article presents the overview of occupational diseases in the Czech Republic in the year 1998. The total number of diseases was 2111, the incidence per 100,000 employees was 45.8. It is necessary to present and discuss unifying criteria for occupational diseases in European countries, as well as the minimum level of the damage, that could be called an occupational disease. The criteria should be co-ordinated, because in a unified Europe, there will be many more possibilities for change in the workplace.

A framework for addressing health issues in or near a manufacturing facility

Clustering of health events in or around industrial facilities sometimes leads to worker and community concerns that plant management or local health professionals must address. We provide an eight-step process to deal with these concerns systematically. We emphasize the use of good scientific practices with managerial oversight for effective worker and community communication. This process is directed to plant management and the local health professional and emphasizes the practical aspects of the investigation.

Improving readiness and fitness of the active military force through occupational medicine tenets

The United States Military deploys its forces with minimal lead time. These forces must be medically qualified and physically fit for any locale and mission scenario. Historically, up to half of the force identified for deployment at any given time were not medically qualified. Matching individuals to specific occupations using validated medical and physical performance standards is an occupational medicine tenet that increases the effectiveness and efficiency of the workforce. To establish a cost-effective, valid medical program ensuring a fit and ready force, the military must: (1) develop validated physical fitness/occupational standards; (2) consolidate one fitness standard for males/females on the basis of workload requirements; (3) eliminate differing age standards; (4) provide statistically relevant medical screening, testing for health maintenance, and fitness for duty; and (5) mandate one joint medical standard for all military services.

State licensing laws and the interstate practice of occupational medicine

In 1996, the Occupational Health Law and Policy Section of the American College of Occupational and Environmental Medicine (ACOEM) was asked to undertake a study of state licensing regulations after the prosecution of an ACOEM member for practicing medicine without a license. In response to that member's experience, the ACOEM House of Delegates passed a resolution asking the College to lobby individual states for an exclusion to their licensing acts for occupational and environmental physicians. Recognizing the tremendous obstacles to this task, the ACOEM Board of Directors then referred the issue to the Occupational Health Law and Policy Section for further study and analysis. What follows is a report of that study, including the results of a survey mailed to the licensing authorities of the 50 US states and four US territories. The results of this study are not meant to offer advice to College members regarding compliance with specific state licensing regulations, nor does it define the official position of the states that responded. States that responded were careful to disclaim their responses as the official position of their states' agencies and were assured that the responses were provided for informational purposes only. The purpose of the survey was not to provide information for reference but simply to identify general trends and document the various positions that states may take on certain licensing issues.

Relation between indicators for quality of occupational rehabilitation of employees with low back pain

OBJECTIVES

To assess if the implementation of guidelines for occupational rehabilitation of patients with low back pain by means of process variables--a set of objective criteria for technical performance and continuity of care--led to a better outcome in clinical and return to work variables.

METHODS

The study group consisted of 59 patients with at least 10 days of sick leave because of low back pain. Univariate analyses as well as multiple logistic regression and Cox's regression analyses were performed to assess the relation between quality of care and outcome.

RESULTS

Process indicators for technical competence, continuity of care, and total performance were all significantly related to satisfaction of employees. Continuity of care and total performance were significantly related to working status at 3 months, and time to return to work. None of the process indicators was related to pain or disability after 3 months follow up. Satisfaction was not related to any of the other outcome variables. This indicates that if guidelines for occupational rehabilitation are met, outcome is better.

CONCLUSION

Quality of the process of care was related to outcome. Interventions of occupational physicians need improvement in the areas of continuity of care and communication with treating physicians. The effectiveness of an improved intervention should be studied in a subsequent randomised clinical trial.

Problematic or practical? Professional body occupational health guidelines

This paper focuses upon conflict between professional and managerial values in an occupational health setting. Findings are presented which suggest that the guidelines issued by UK occupational health professional bodies (describing the duties and responsibilities of occupational health professionals), have been perceived by professionals as being impractical because they tend to focus on the theoretical role of the professional at the expense of the reality of the experienced role. The paper concludes that the problem does not actually lie with the guidelines, but with the perception of the guidelines. It is suggested that this problem can be addressed by empowering occupational health professionals to interpret and tailor the guidelines to suit their particular working environment. In addition, encouraging occupational health professionals to pro-actively market their role, will result in awareness raising amongst the managers for whom they work who often have inappropriate expectations of the occupational health professionals.

[Professional integrity among commercial occupational health services]

In the field of Occupational Health Services (OHSs) a fundamental change of the regime of supply of services was implemented in the Netherlands between 1993 and 1998 by introducing market competition. This regime change is characterised as a shift from a suppliers' market where occupational physicians were able to determine the supply to a large extent, to a buyers' market where companies can choose from a large variety of services at different prices. The regime change does affect the position of the occupational physician drastically and many consider their professional integrity and independence threatened. To meet the demand for an independent judgement and advice in problems concerning the interaction between work and health, the professional group should organize itself more as a party in the market.

Decision model for optimizing respirator protection

Respirators are widely used for protection against inhaled toxins. The emphasis of research and implementation effort has evolved through several stages: the respirator device itself, use situation, respirator program factors under employer control, individual worker factors not under employer control, and occupational health systems. For this study, a computer-simulation decision assistance model was developed to assess the impact of various factors on the number of workers receiving adequate protection. Factors include the respirator protection factor, identification of sites needing respirator protection, selection of proper device, availability when needed, frequency of ever use, regularity of use among users, and variability in personal susceptibility or other factors. This analysis demonstrates that for both moderate-risk and high-risk (i.e., IDLH, immediately dangerous to life and health) exposures under current circumstances, the actual protection afforded depends upon the optimization of program factors and detection of atypical outlier persons and worksites. Therefore, programs and research must focus on these areas. Occupational medicine specialists should help optimize these areas and, in addition, use each case of respiratory protection failure as an index case to improve the overall programs.

Some theoretical remarks regarding the integration of somatic and psychosocial risk factors of coronary artery disease in preventive programmes in occupational medicine

In occupational medicine, as well as in many other medical areas, we still find too frequently a disturbing polarization of 'natural science oriented' versus 'psychosocial oriented' medicine. This has its roots in Descartes' traditional division of res cogitans (thinking substance) and res extensa (extended or corporeal substance). It would be important for medicine to integrate modern physics, where quantum theory plays an essential role, into its natural science base. In modern physics, the Cartesian division can no longer be consistently maintained as it has been in classical physics and related natural sciences. Taking the recent developments and new aspects of modern natural science into consideration for application in medical thinking would facilitate greatly the desirable unified, holistic approach, necessary to overcome the problems of the Cartesian division still present, and to better integrate somatic and psychosocial aspects of medicine. This is important for the general planning of programmes of preventive medicine in occupational health as well as in other medical fields. It is also essential specifically in treating individual patients and their medical problems. This is demonstrated here using the example of coronary artery disease (CAD). Treatment and prevention of CAD, a main cause of morbidity and mortality in industrialized countries, is a major challenge for all of medicine, including occupational medicine.

[Asbestos-related occupational lung diseases. Role of the pneumology unit in screening and compensation]

The application of new decrees concerning the protection of individuals against sanitary risks linked to the various possible expositions to asbestos dusts is leading to a growing involvement of pulmonologists in diagnosis procedures not only for active workers regularly examined via the occupational medicine healthcare system, but also for those who are no longer, the unemployed or retired previously exposed to asbestos fibres. The present chapter presents and comments the revised guidelines about the compensation procedures for occupational diseases, and provides useful recommendations for establishing the records leading to their medical assessment. It emphasises the importance of a close cooperation between pulmonologists and radiologists in order to avoid radiation overdosing, which could increase the risk of lung cancer, as much as possible.

Polish approach to the quality assurance system in occupational health services

The most important factors which influence the quality of Occupational Health Services in Poland are discussed. The legal regulations, the system of specialist education, guidelines and standards in occupational medicine, and the role of regional specialists supervision system are presented. The audit of medical documentation revealed the 'sub-populations' of doctors who are concerned about the quality and those who are not. Keeping relatively moderate prices of services by some OHS units, even at the cost of their quality, has become a side-effect of competition. The establishment of an accreditation system in OHS is postulated, basing on the existing elements of such a system.

[Limitations in using international occupational disease statistics for comparative analysis]

The comparability of international statistical data on the incidence of occupational disease is discussed. The examples of some countries served to present the reasons why the relevant data available in publications cannot be often used as a frame of reference to comparative studies. The problem results mainly from different definitions of the term "occupational disease" as they frequently include in their context also these pathologies which are numbered among work-related diseases. In addition, the authors highlighted the steps undertaken by international organizations (World Health Organization, International Labour Organization, and European Union) to unify both the diagnostic procedures and the system of collecting and publishing of statistical data on occupational diseases.

Occupational medicine practice guidelines

Practice guidelines have become accepted "rules of the road" for many illnesses and injuries. Guidelines can be the basis for performance measures if they include a development step summarizing the available evidence for efficiency and effectiveness of maneuvers, tests, and treatments. They are particularly valuable for entities that have high degrees of variance in diagnostic accuracy, testing, and treatment. Periodic revision of guidelines can keep professional knowledge bases up to date. One must keep in mind that guidelines are just that--descriptions of normative data, observed best practices, expert consensus, or high-grade evidence. While they provide benchmarks for assessment and improvement, there may be good reasons why they do not apply to some patients. However, the exercise of justifying the differences can sharpen clinical judgment and improve outcomes.

[Occupational medicine and quality]

The discipline of occupational medicine has always maintained a closed relationship with the quality system, starting from the well known quality assurance practices, up to the quality of health services, and the concept of prevention and health promotion as essential components of quality programs. The quality of health care has emerged as an area of high interest and concern, driven by the consideration of public policy and the desire of health care government to maximize the value of their investments. However, when we move to apply quality principles to health service some difficulties emerge. For example the introduction of DRFs system makes uneconomical the diagnosis in occupational medicine, since the costs are determined by the type and the number of hazards to be identified and assessed and not only by the risk factors of by the worker's pathology. Moreover, resources are necessary for the correct evaluation of non occupational pathologies often present, both for deontological and legal reasons. The attention to the role of occupational medicine in quality programs has been increased by the recognition of the adverse impact of preventable or controllable risk factors in health benefit and disability costs and employee productivity. By this way prevention and health promotion will become an essential part of quality procedures able to guarantee and maintain quality objectives.

Managed care workers' compensation outcome measurements: how can a clinic compete?

Clear guidelines and standards established for physicians by managed care organizations are not similarly applied to clinics. Generally, measures of quality of care and service for clinics are ill-defined. Dr. Mueller details six steps to creating a meaningful, achievable set of outcome measures so that clinic organizations can improve and promote their care.

Performance measures in occupational medicine: a tool to manage quality

Managed care in occupational medicine has cut costs of workers' compensation. However, quality of care may have received less-than-optimal attention. The use of quality indicators is a new phenomenon.

Managed occupational health

This chapter explores the elements and techniques of managed care, managed health, and good management in general to identify key success factors in programs addressing prevention, care, disability, and rehabilitation.

The market for occupational medicine managed care

The metamorphosis of the health care market has opened a window of opportunity for occupational medicine programs and practices to assume a critical role in the delivery of managed occupational and personal health care services. This chapter offers practical suggestions and tips.

[Evaluation of the nervous system in workers as needed for preventive care. Methodical indicators. II. Objective examinations]

A model of medical examinations useful in general evaluation of the nervous system was proposed. It is designed for doctors of occupational health services who perform prophylactic examinations but they are not neurologists. Technically simple elements of routine neurological examinations are selected. They are easy to perform and provide most observations which can be interpreted by a doctor who is not specialised in neurology.

[A survey on return to work and fitness for work in Japan: the systems provided in corporate regulations and their application]

We conducted a survey to evaluate the current situation and the application of systems for return to work (RTW) and fitness for work (FFW) in Japanese companies. Self-administered questionnaires were mailed to 351 occupational health (OH) physicians listed in the membership directory of the Japan Society for Occupational Health published in 1990. The item of information sought were the size and industrial type of the company, the organization of OH staff, the process of assessment of RTW, the provision for sick leave in corporate regulations, the FFW criteria, and job training systems for RTW. Of the 145 companies from which questionnaire replies were received from OH physicians (response rate: 41%), 123 (85%) were manufacturing industries. When classified according to the number of employees, 41 (28%) had 3000 or more, 66 (46%) had between 1000 and 2999, 26 (18%) had 999 or fewer and 12 (8%) were unknown. 144 companies (99%) had provisions on temporary retirement in their corporate regulations. As for who makes compensation during temporary retirement, 66 (48%) and 61 (44%) companies answered "both company and health insurance society" and "health insurance society alone," respectively. 136 companies (94%) carried out assessment of RTW, and involved OH professionals and other related staff in the process of assessment. In the majority of cases, the OH physicians were in charge of the decision-making process on RTW and were authorized to make the final decision. In the companies with 3000 or more employees, the cases of longer-term sick leave were assessed in a more complete process than those of shorter-term sick leave. 119 companies (88%) conducted on additional health examination to assess the employee's FFW. Sixty-four companies (47%) had standardized criteria on FFW. One hundred and eighteen companies (83%) had job training systems for employees' RTW, and they mainly introduced restricting one's job and/or reducing one's work-load. It was suggested that complete systems for RTW and FFW were more available among companies with 3000 or more employees than among companies with 2999 or fewer employees.